The Medical Advancement of Personal Needs 
By Vincent M. Riccardi, MD

Among the many types of responsibilities for caregivers, there are three I wish to address here: those that are clearly medical, those that clearly address personal needs and those in the gray area in between. First, let’s consider the three categories. Physicians, nurses and other clinicians, most often assume medical responsibilities but, under special circumstances, the patient or caregiver may take over, at least temporarily. The responsibility for personal needs, such as bathing and feeding, is almost entirely assumed by the patient or the caregiver, except when the patient occupies a bed in hospital or nursing home. The gray area of responsibility is the main focus of this piece. Examples include the administration of insulin by injection, taking the pulse and blood pressure, and so on.
My prediction is that with increasing speed we will see a shift in the number of responsibilities from the medical arena and health care professionals through the gray zone to caregivers to attend simply as personal needs. Healthplans will be covering fewer and fewer benefits. That is, medical responsibility – as defined by those paying for them as benefits – will be more and more circumscribed.

When I graduated medical school in June 1966, I considered it one of my primary responsibilities to characterize almost any need a patient had as being appropriately covered as a benefit under the patient’s healthplan. Physicians were essentially able to establish medical necessity by declaration. Another way to look at it is that I participated in an American cultural and social movement to medicate essentially all the needs of patients. If the patient had a need, we construed it as representing a medical necessity.

I cannot pretend to know all of the reasons for such an approach on a national scale. But, I do know it was there and that I was an enthusiastic participant, a part of the apparent triumph of the downtrodden over corporate America. However, medical advancement had other origins as well, including an increasing emphasis on public health and preventive medicine. What you ate became a medical matter. Cigarette smoking became a medical matter. Jogging and other exercise became a medical matter. Automobile seatbelts became a medical matter. Within a short period of time – perhaps a decade – every activity had a medical basis and history in America. This was good for many people. The notion was that anything that had to do with health, well-being and normal functioning was “medical” and therefore a covered healthplan benefit.

With the widespread adoption of the managed care mentality, putting a premium on minimizing expenditures, one option for doing so became paramount: declaring that a particular need or consequent service no longer is considered to be “medical.” For example, mental health disorders were declared totally separate in terms of medical decision-making and financial responsibilities of healthplans. If your heart is sick, they’ll spend thousands and thousands of dollars. If your brain is sick, maybe you only receive a few hundred dollars. Why? Who made these decisions, and under what authority?

In the meantime, my focus here is on the increasing exclusion of needs and services that could be attended to or provided by caregivers. One of the most important areas of medical consumer contention that I deal with daily is the denial of payment for services because the services can be provided by a caregiver, even though just a few years ago they were almost automatic healthplan benefits. And the pattern will continue with increasing intensity. Healthplans and professional medical groups (who do almost all of the utilization review and denials of healthcare benefits) are becoming looser and looser in their determination that a patient with a stroke has “plateaued” or merely requires “custodial” care. This simply translates into caregivers (if the patient has them) assuming the responsibilities for maintaining the health and well being of the patient.

This trend will continue. Caregivers will assume financial and hands-on responsibility for what in the 60’s, 70’s and early 80’s was provided by healthplans. Be ready. One of the ways to be ready is to be willing to use organizations with names giving the sense of “Caregivers ‘r’ Us,” allowing for hiring of people to provide the various services that traditional caregivers provide. Such expenses will be outside the realm of medical necessity and benefits. Over the long run, there will be a need for caregivers to choose whether relegation of such expenses to non-reimbursable costs is appropriate or that the medical advancement of such services is most appropriate. Please choose deliberately and choose wisely.

 

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